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Pseudo-Class III malocclusion treatment with Balters’ Bionator

Article  in  Journal of orthodontics · October 2003

DOI: 10.1093/ortho/30.3.203 · Source: PubMed

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 Journal of Orthodontics, Vol. 30, 2003, 203–215

CLINICAL
SECTION
Pseudo-Class III malocclusion
treatment with Balters’ Bionator
A. Giancotti, A. Maselli, G. Mampieri and E. Spanò
University of Rome ‘Tor Vergata’, Rome, Italy

Abstract The aim of this article is to show the use of the Balters’ Bionator in pseudo-Class III treatment.
The importance of differentiating between true Class III and pseudo-Class III is emphasized. The
therapeutic results of a Balters’ Bionator appliance are presented in three case reports of subjects
in the mixed dentition. In this stage of development it is possible to correct an isolated problem.
Index words: Anterior The use of the Bionator III in this kind of malocclusion enabled the correction of a dental
crossbite, Bionator III, malocclusion in a few months and therapeutic stability of a mesially-positioned mandible
pseudo-Class III encouraging favourable skeletal growth.

Received 10 January 2002; accepted 6th December 2002

Introduction into an anterior position and has been named in a

Skeletal, aesthetic, and occlusal characteristics of pseudo-
Class III have been highlighted in different articles, and
have been compared with normal occlusion, Class I
malocclusion, or skeletal Class III malocclusion.1–3
The incidence of Class III malocclusion is variable and
depends upon the different methods of classification
used. Class III malocclusion in white subjects occurs in
fewer than 1 per cent of the population, while frequency
in the Japanese population is approximately 10 per cent.1
However, the incidence of pseudo-Class III malocclu-
sion in a sample of 7096 Chinese children was estimated
to be 2–3 per cent.
Nakasima1 has reported that the incidence of anterior
crossbites has a strong ethnic distribution, particularly
high in Japanese subjects and Ferguson4 has reported
that an anterior crossbite could be observed in 3 per cent
of patients in the United States.
Dental features, diagnosis, and
aetiology
Mesio-occlusion is an anteroposterior dentoalveolar
relationship characterized by a more anterior position of
the mandibular dentition compared to the maxillary
dentition.1 Clinically, there are two types of mesio-
occlusion. The first type is considered to be a positional
form, as a result of a mesial displacement of the mandible
Address for correspondence: Dr Aldo Giancotti, Via Barnaba Tortolini 5, 00197 Rome – Italy. E-mail: giancott@uniroma2.it
different ways (pseudo, functional or apparent…). The
other form of mesio-occlusion is a true skeletal Class III.
The characteristics of this malocclusion result from a
combination of skeletal and dentoalveolar features.
Careful clinical evaluation of Class III malocclusion
always requires checking anterior and posterior dental
relationships with the mandible in centric relation.
Moyers proposed the pseudo-Class III relationship as a
positional malocclusion with an acquired neuromuscular
reflex, and considered the hypothesis that the positional
relationship in ‘apparent Class III’ may occur with an
early interference with the muscular reflex of mandibular
closure.5 Subjects with pseudo-Class III malocclusions
mainly present with Class I or mild Class III skeletal
relationships, while the mandible appears morphologic-
ally normal. However, anterior crossbite and negative
overjet are constantly present due to the anterior man-
dibular displacement. Usually, the soft tissues tend to
camouflage the skeletal discrepancy and the patient’s
profile appears normal or slightly concave in centric
occlusion. Different aetiological factors have been sug-
gested in pseudo-Class III malocclusion.6
Dental factors
• Ectopic eruption of maxillary central incisors
• Premature loss of deciduous molars
 204 A. Giancotti et al. Clinical Section
Functional factors
• Anomalies in tongue position
• Neuromuscular features
• Naso-respiratory or airway problems
Skeletal factors
• Minor transverse maxillary discrepancy
It has also been suggested that these sequelae occur
more frequently in subjects with a prognathic mandible
(primary cause) and the mandibular shift can be con-
sidered a functional (environmental) factor, therefore the
postnatal causative factors may not be the primary
cause.1
Management of pseudo-Class III
malocclusion
The pseudo-Class III malocclusion involves both per-
manent teeth and the deciduous dentition.
Because a malocclusion may be regarded as an aesthetic
problem, parents often inquire whether or not therapy
might be required. Several clinicians believe in the
advantages of early intervention and have suggested a
number of reasons for early correction of anterior cross-
bite even in the deciduous dentition. The optimum period
for the treatment suggested to be between the ages 6–9
years.7–10
Many practitioners however still avoid early correction
of pseudo-Class III in the deciduous dentition because
of poor stability of correction and unfavourable experi-
ences with the behaviour of young patients. Patients may
develop a crossbite once again during the transitional
dentition, thus requiring further treatment and this may
represent a possible disadvantage of treatment at early
stage.
Some practitioners prefer to wait for the permanent
maxillary incisors to erupt before initiating therapy due
to the natural tendency of teeth to erupt in a lingual
position during dental arch development. Sometimes,
functional deciduous anterior crossbites occasionally
correct themselves spontaneously.
White has suggested intervention in cases of pseudo-
Class III malocclusion in the mixed dentition when the
maxillary and mandibular incisors have erupted. 12 This
allows the permanent teeth to erupt into a better position
and improves the dental aesthetics.
The benefits attributed to the treatment of pseudo-
Class III malocclusion in the mixed dentition are:
JO September 2003
• preventing unfavourable growth of skeletal compon-
ents (in fact, early treatment of anterior crossbite can
help to minimize adaptations that are often seen in
severe late adolescent malocclusion);2
• preventing functional posterior crossbite and habits,
such as bruxism that can develop from anterior or
posterior interferences;11
• gaining space for eruption of canines (lack of space
could be caused by retro-inclination of upper incisors
frequently found in pseudo or Class III malocclusion);3
• avoiding the risk of periodontal problems to man-
dibular incisors caused by the traumatic occlusion due
to the crossbite.
Use of Bionator in Pseudo-Class III
malocclusion in mixed dentition
Several studies have suggested that almost 20 per cent of
patients presenting with a Class III malocclusion can be
treated during the mixed dentition. At this stage of
development it is possible to correct an isolated problem
or provide preliminary treatment.12,13 Anterior crossbite in
the mixed dentition should be corrected to allow normal
dental development and subsequent favourable skeletal
growth.
Studies have confirmed the efficiency of the Bionator in
the treatment of Class III malocclusions. Clinical experi-
ence has shown the importance of differential diagnosis
and suggested that individualization of the appliance
is important for good results.14 Functional orthopaedic
appliance therapy is one approach to the treatment of
pseudo-Class III malocclusion. The Bionator, developed
by Balters is a derivative of the Activator.
His design has a palatal wire and also a wire with
‘buccinator wings’ to reduce cheek pressure, while the
amount of acrylic is reduced. The Bionator can be worn
both day and night.5
The reverse Bionator or Bionator III is a modified
version of the traditional bionator and can be used in
the treatment of Class III malocclusion. The modified
Bionator differs in various characteristics from the ori-
ginal appliance. The lingual wire is in a different position
to control the position of the tongue up to the upper first
molar. The labial arch is placed in the middle of the lower
teeth (Figure 1). The acrylic should be made as small as
possible in order to occupy minimal space and should
have a concave form to accommodate the tongue. The
occlusal acrylic should be thick enough to obstruct
tongue movement between the posterior segments.
The vertical occlusal height should be enough to correct
 JO September 2003 Clinical Section Malocclusion treatment with Balter’s Bionator 205

in the anterior part of the palate, pushing it against the

upper front teeth. The vertical thickness of the bite was
3–4 mm with sliding guides in the posterior zone.
The patient had to wear this Bionator for 16 hours a day
(Figure 4).

Results. The incisors were beyond edge-to-edge after 9

Fig. 1 Balters’ Bionator described in this article.
the anterior crossbite, but should not exceed 3–4 mm. The
construction bite is taken by positioning the mandible
posteriorly into centric relation.
Finally the acrylic vestibular lateral shields should be
positioned to allow lateral alveolar growth in order to
permit expansion of the maxillary arch.
Case reports
weeks, but use of the Class III Bionator was continued.
Eleven months after the beginning of treatment the
patient had a normal occlusion with 2-mm overjet and
a Class I molar relationship. Final records showed
excellent occlusal and aesthetic results, and the profile
was relatively normal with a good lower lip position
(Figure 5). Cephalometric tracing demonstrated a reduc-
tion of 3 mm in the Wits measurement and a retro-
inclination of the lower incisors with a reduction of the
angular and linear measurements (22 degrees, 3 mm to
NB; Table 1).

Case report 1 Table 1 Case 1 cephalometric summary

A female patient, age 8 years 10 months, presented with Measurement Normal Initial Final
an anterior crossbite from the upper right deciduous
SNGOGN 32 40 38
canine to the upper left deciduous canine and a 1-mm
PocGoGn 16 20 18
deviation of the mandibular midline to the right (Figure. FMA 25 33 33
2). The patient had a good profile with a slight mid-face
convexity and the lower lip appeared protruded (Figures SNA 82 81 82
2 and 4). She was in the mixed dentition and the initial SNB 80 79 80
panoramic radiographs revealed that all permanent teeth ANB 2 2 2
AoBo 0.3 mm 6 mm 3 mm
were present. The upper anterior teeth were retroclined
and the upper right lateral incisor was missing, while the 1/NA 4 mm 3 mm 4 mm
lower anterior teeth were protrusive. The molars were in a 1/NA 22 29 29
Class I relationship. The lower arch was in the late mixed 1/NB 4 mm 5 mm 3 mm
dentition and ‘E’ space was present; right and left man- 1/NB 25 29 22
FMIA 65 63 62
dibular second primary molars had exfoliated (Figure 2).
IMPA 90 84 85
Pre-treatment cephalometric analysis showed an in- 1/1 131 128 130
creased mandibular plane angle (40 degrees), with a
normal ANB, but a high Wits measurement (6 mm) NLA 90 90 80
and the lower incisor inclination was 29 degrees to NB.
Angular and linear measurements of mandibular skeletal Case report 2
growth were normal. Clinical evaluation of the occlusal
relationship in centric relation showed an early inter- The second case report was a 9-year-old girl presenting a
ference of the upper left central and lower left central convex profile, protruding lower lip and anterior cross-
incisors (Figure 3). bite. She had a Class III malocclusion in the mixed
dentition (Figure 6).
Treatment progress. An early treatment goal was to An anterior interference was evident when evaluating
eliminate the mandibular displacement and treatment the occlusal relationship in centric occlusion (Figure 7).
was initiated with a Balters’ Bionator III. In order to Cephalometric analysis revealed a Class I skeletal
construct the Bionator a wax bite was taken by distally relationship with ANB  2 degrees. Angular measure-
repositioning the mandible in centric relation. This use ments of the maxilla could be considered normal, but
of the Bionator III thus enabled the tongue to move freely linear measurements suggested mandibular protrusion
 206 A. Giancotti et al. Clinical Section JO September 2003

(a) (b) (c)

(d) (e) (f)

(g)

(h)

Fig. 2 Case 1: pre-treatment records and cephalometric tracing.

 JO September 2003 Clinical Section Malocclusion treatment with Balter’s Bionator 207

(Wits  5 degrees). Dental patterns revealed upper

incisor retroclination (1 mm, 17 degrees to NA) and
proclination of lower incisor (5 mm, 35 degrees to NB).
The nasolabial angle was acute (Table 2).

Treatment progress. The objectives of the treatment were

to procline the upper incisors, eliminate the mandibular
displacement and create the space necessary for the
eruption of the upper right lateral incisor. Because of Fig. 3 Case 1: intra-oral view before treatment; an early interference of
skeletal Class III measurements we decided to use a the upper and lower left central incisors in centric relationship is detected.
functional appliance. A Class III Bionator was used for

(a) (b) (c)

Fig. 4 Case 1: intra-oral view during the treatment with Balters’ Bionator.

14–16 hours a day for a period of 90 days (Figure 8). Table 2 Case 2 cephalometric summary
At the end of the treatment period the following results
were obtained: a labial inclination of the upper incisors Measurement Normal Initial Final

possibly due to tongue pressure and a retroclination of SNGOGN 32 33 33
the lower incisors due to the action of the Bionator wire. PocGoGn 16 16 11
Both of these factors contributed to the correction of the FMA 25 26 24
anterior crossbite and the elimination of the mandibular
SNA 82 82 83
displacement (Figure 9).
SNB 80 80 80
Also, the right buccal crossbite was eliminated by using ANB 2 2 3
occlusal ramps built up on the mandibular permanent AoBo 0.3 mm 5 mm 3 mm
and deciduous molars (Figure 10).
Results. After 24 months of treatment a good occlusion 1/NA 4 mm 1 mm 2 mm
1/NA 22 17 26
was achieved, with a Class I canine and molar relation-
1/NB 4 mm 5 mm 4 mm
ship (Figure 11). 1/NB 25 35 30
Cephalometric averages demonstrated little change FMIA 65 52 58
of linear and angular mandibular measurements. The IMPA 90 102 98
maxillary incisors were uprighted to 2 mm and 26 degrees 1/1 131 126 121
to NA, while lower incisors were retroclined to 4 mm,
NLA 90 81 86
30 degrees to NB. The nasolabial angle increased up to
5 degrees, with a pleasing aesthetic effect on the profile
(Table 2). of mandible (Figure 12). The patient had a bilateral Class
III malocclusion, which was more pronounced on the
right side, and an anterior crossbite with a 4-mm devi-
Case report 3
ation of the mandibular midline to the left. The upper
A 9-year-old female presented with a retruded soft-tissue anterior teeth were retroclined and a minor rotation of
profile, normal facial growth with very little protrusion these teeth was visible.
 208 A. Giancotti et al. Clinical Section JO September 2003

(a) (b) (c)

(d) (e) (f)

(g)

(h) (i)

Fig. 5 Case 1: post-treatment records, cephalometric tracing and superimposition after 11 months of active treatment.
 JO September 2003 Clinical Section Malocclusion treatment with Balter’s Bionator 209

(a) (b) (c)

(d) (e) (f)

(g)

(h)

Fig. 6 Case 2: pre-treatment records and cephalometric tracing.

 210 A. Giancotti et al. Clinical Section JO September 2003

The lower anterior teeth were protruded and over- Results. After only 2 months of therapy, the patient
erupted. presented an edge-to-edge incisor relationship.
Cephalometric analysis indicated a small Class III mal- It was decided to continue the therapy in order to
occlusion characterized by a little mandibular protrusion
(ANB  1 degree, Wits 6 mm). The mandibular
position was due to a premature of the left central incisors
and subsequently mandibular displacement (Figure 13).

Treatment progress. The aims of this treatment were

to obtain a Class I occlusion, correct the mandibular
displacement and eliminate the premature contact
between the two incisors. Due to the patient’s age, it was
advisable to use a functional appliance and a Bionator III
was chosen. The patient was instructed to wear it for 15 Fig. 7 Case 2: intra-oral view before treatment; an early interference of
hours a day (Figure 14). upper and lower right central incisors in centric relationship is detected.

(a) (b) (c)

Fig. 8 Case 2: Balters’ Bionator in place at beginning of treatment.

(a) (b) (c)

Fig. 9 Case 2: clinical observation 90 days later.

(a) (b) (c)

Fig. 10 Case 2: occlusal ramps used for to treat posterior crossbite on right side.
 JO September 2003 Clinical Section Malocclusion treatment with Balter’s Bionator 211

(a) (b) (c)

(d) (e) (f)

(g)

(h) (i)

Fig. 11 Case 2: post-treatment records, cephalometric tracing and superimposition.

 212 A. Giancotti et al. Clinical Section JO September 2003

(a) (b) (c)

(d) (e) (f)

(g)

(h)

Fig. 12 Case 3: pre-treatment records and cephalometric tracing.

 JO September 2003 Clinical Section Malocclusion treatment with Balter’s Bionator 213

improve and stabilize the results obtained. After 7

months a good occlusion with a Class I canine and
molar relationship was obtained. The patient presented
a normal overbite and overjet and the midlines were
coincident (Figure 15). Final superimpositions showed
improvements in the linear and angular dental values.
The slight maxillary protrusion coupled with the
clockwise mandibular rotation produced an overall
improvement of the patient’s aesthetic appearance. A Fig. 13 Case 3: intra-oral view before treatment; an early interference of
slight downward and forward mandibular growth, has first upper and lower left incisors in centric relationship is detected (black
occurred which will continue to be regularly monitored arrow).

(Table 3).

(a) (b) (c)

Fig. 14 Case 3: Balters’ Bionator in place at beginning of treatment.

Discussion Table 3 Case 3 cephalometric summary

The various treatments suggested in the literature for the Measurement Normal Initial Final
correction of anterior crossbite include several different
SNGOGN 32 31 30
appliances, both fixed and/or removable with heavy- PocGoGn 16 16 16
intermittent forces (inclined bite-plane, tongue blade) FMA 25 22 20
or light-continuous forces (removable appliance with
auxiliary springs). SNA 82 83 82
Other alternative therapies that may correct skeletal SNB 80 84 82
ANB 2 1 0
problems in young patients have been shown to be effec-
AoBo 0;3mm 6mm 4mm
tive, with significant changes in the cranio-facial complex,
including the use of protraction headgear,15 chincap,16 1/NA 4mm 0 7mm
and Frankel III.17,18 1/NA 22 23 30
Turley presented the therapeutic results of orthopaedic 1/NB 4mm 3mm 3mm
1/NB 25 26 21
treatment with palatal expansion and custom protraction
FMIA 65 68 70
headgear.19 Patients of 6–9 years of age can be brought to IMPA 90 90 90
a normal occlusion in less than a year and this therapeutic 1/1 131 132 132
approach also suggests that with proper diagnosis early
Class III treatment can produce good results. Tsai sug- NLA 90 84 90
gests the use of rapid palatal expansion and standard
edgewise appliance to resolve an anterior crossbite in a
7-year-old boy.20 incisors contribute to the correction of anterior crossbite
Rabie and Gu have described a simple method for the and the elimination of mandibular displacement. The
early treatment of pseudo-Class III malocclusion in the early treatment also permits us to gain space for canine
mixed dentition with fixed appliance.21 Proclination of eruption.
the upper incisors and/or retroclination of the lower The therapeutic use of a Balters’ Bionator appliance is
 214 A. Giancotti et al. Clinical Section JO September 2003

(a) (b) (c)

(d) (e) (f)

(g)

(h) (i)

Fig. 15 Case 3: post-treatment records, cephalometric tracing and superimposition.

 JO September 2003
suggested in three case reports of subjects with anterior
crossbite in mixed dentition. The patients all present with
a convex soft-tissue profile. Pre-treatment cephalometric
analysis showed an high mandibular plane angle in the
first case, but the other two cases presented a normal
growth with very little protrusion of the mandible.
Dental patterns revealed upper incisor retroclination
and proclination of lower incisor in all cases.
The clinical examination revealed that the displacement
was due to a premature contact between the upper and
lower incisors.
Conclusion
The patients all wore the Bionator approximately 15
hours daily for a period of 60–90 days.
At the end of this period in all cases the correction of
anterior crossbite and the elimination of the mandibular
displacement were obtained, but the use of a Class III
Bionator was continued for a further to maximize
chances of stability.
The literature demonstrates that functional appliances
work in correction of anterior crossbite. The suggested
advantages of this approach are as follows:
• prevents unfavourable growth especially mandibular
protrusion;
• prevents habits such as bruxism;
• eliminates traumatic occlusion and anterior crossbite;
• eliminates the need for using bands and brackets, thus
reducing the length of time that fixed appliances must
be worn with all associated benefits, prevents functional
posterior crossbite.
Principal disadvantages of Bionator treatment include
the following:
• the final alignment of the teeth, is impossible without
fixed appliance;
• cooperation from the patient is essential for the success
of this approach.
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